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HomeMy WebLinkAboutBldp-20-000152 (2) Yam '.. MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK 'j ::\- . W �� � C `... ��," CIT`( � tL7l. 4 DATE� ��� PERMIT# JOBSITE ADDRESS 6 & fJ� ,, 112,41: 4- 16 i-2 , OWNER'S NAME >t)xa L'!/ o GOWNER ADDRESS TEL6 -07f,K2 FAX TYPE OR PRINT OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL CLEARLY NEW:❑ RENOVATION: ❑ REPLACEMENT: RI/ PLANS SUBMITTED: YE IJO- APPLIANCES 1 FLOORS—I BEM 1 2 3 4 5 6 7 8 9 10 11 12 '13 14 BOILER ■ BOOSTER — 1 CONVERSION BURNER COOK STOVE DIRECT VENT HEATER DRYER i FIREPLACE 1 FRYOLATOR _ FURNACE GENERATOR. II GRILE ■111PIE ■ ❑ INFRARED HEATER —� LABORATORY COCKS MAKEUP AIR UNIT ■ ■ --?il� i OVEN __ �=j . �r�CT-_' �11.31 POOL HEATER Mar I' . ,��' Evio/ ROOM;SPACE HEATER ■ 1E11 I Ritillig1111111 1 ROOF TOP UNIT F11. TEST ... t D1Ne DE-P UNIT UNVENTED ROOM HEATER WATER HEATER IIMI OTHER INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of IIIIGL.Ch.142 YES,[] NO ❑ I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY ❑/ OTHER TYPE INDEMNITY ❑ BOND ❑ • OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts General Laws,and that my signature on this permit application waives-this requirement. 1 CHECK ONE ONLY: OWNER ❑ AGENT ❑ SIGNATURE OF OWNER OR AGENT i • -, I hereby certify that all of the details and information I have submitted or entered regarding this application are true and accurate to the best of my knowledge `;:- and that all plumbing work and installations performed under the permit issued for this application will be in complianc9,with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. I © I PLUMBER-GASFITTER NAME CJd i Al✓s LICENSE# SIGNATURE MP MGF❑ JP 0� JGF 0 LPG! ❑ CORPORATION El PARTNERSHIP❑# LLC(! ti 21 1COMPANY NAME��ljr �/11c ,['//C/ ADDRESS / .1 .1ia 4i CITY //v' '/i STATE4/0 ZIP ( ,6 TEL 749 7/1)2 /7" FAX CELL EMAIL / ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVES AS THE PERMIT • ❑ ❑ FEE: $ PERMIT f CX PLAN REVIEW NOTES• 7 /5 • ' Y 4)